Arkansas Department of Human Services...“The Department of Human Services is in compliance with...

Arkansas Department of Human Services Division of Medical Services Donaghey Plaza South P.O. Box 1437 Little Rock, Arkansas 72203-1437 Internet Website: www.medicaid.state.ar.us

“The Department of Human Services is in compliance with Titles VI and VII of the Civil Rights Act.”

TO: Arkansas Medicaid Health Care Providers - Rehabilitative Services for Persons with Mental Illness (RSPMI)

DATE: August 1, 2005

SUBJECT: Provider Manual Update Transmittal #59

REMOVE INSERTSection Date Section Date 213.000 – 213.100 Dates vary 213.000 – 213.100 8-1-05 217.100 – 217.113 10-13-03 217.100 – 217.113 8-1-05 219.141 10-13-03 219.141 8-1-05 224.000 10-1-04 224.000 8-1-05 226.200 10-13-03 226.200 8-1-05 231.000 – 231.200 10-1-04 231.000 – 231.200 8-1-05 252.100 – 252.120 10-1-04 252.100 – 252.120 8-1-05 252.200 10-13-03 252.200 8-1-05 252.420 10-13-03 252.420 8-1-05

Explanation of Updates Section 213.000 is included to explain that RSPMI staff members must provide services only within the scope of their individual licensure and that it is the responsibility of the facility to ensure that the requirement is met.

Section 213.100 is revised to reflect that the 40 hours of training required for paraprofessionals must be classroom hours.

Sections 217.100 through 217.113 are included to clarify the PCP referral process and state that a retroactive PCP referral, if obtained, must be received within 45 days after the date of service.

Section 219.141 is included to add review of treatment plan to the list of services available to residents of a nursing home.

Section 224.000 is included to state that the Seriously Mentally Ill (SMI) or Seriously Emotionally Disturbed (SED) recipient must be seen directly by a physician within one year after the date of the examination and at least every year thereafter. The time frame was previously six months.

Section 226.200 is included to correct an error regarding progress notes.

Sections 231.000 through 231.200 are included to correct procedure codes and modifiers that require prior authorization.

Sections 252.100 through 252.120 are included to change modifiers 22 and 52 to UA and UB respectively.

Section 252.200 is included to clarify the definition of type of service 9.

Section 252.420 is included to provide technical assistance to providers regarding mental health diagnoses versus substance abuse diagnoses.

Arkansas Medicaid Health Care Providers – Rehabilitative Services for Persons with Mental Illness (RSPMI) Provider Manual Update Transmittal #59

Paper versions of this update transmittal have updated pages attached to file in your provider manual. See Section I for instructions on updating the paper version of the manual. For electronic versions, these changes will be automatically incorporated.

If you need this material in an alternative format, such as large print, please contact our Americans with Disabilities Act Coordinator at (501) 682-6789 or 1-877-708-8191. Both telephone numbers are voice and TDD.

If you have questions regarding this transmittal, please contact the EDS Provider Assistance Center at 1-800-457-4454 (Toll-Free) within Arkansas or locally and Out-of-State at (501) 376-2211.

Arkansas Medicaid provider manuals (including update transmittals), official notices and remittance advice (RA) messages are available for downloading from the Arkansas Medicaid website: www.medicaid.state.ar.us.

Thank you for your participation in the Arkansas Medicaid Program.

______________________________________________________ Roy Jeffus, Director

http://www.medicaid.state.ar.us/

Rehabilitative Services for Persons with Mental Illness Section II

213.000 Staff Requirements 8-1-05

Each RSPMI provider shall ensure that mental health professionals are available to provide appropriate and adequate supervision of all clinical activities. RSPMI staff members must provide services only within the scope of their individual licensure. It is the responsibility of the facility to credential each clinical staff member, specifying the areas in which he or she can practice based on training, experience and demonstrated competence.

Minimal staff requirements for RSPMI provider participation in the Arkansas Medicaid Program are: A. A Chief Executive Officer (CEO) with professional qualifications and experience as

established by the provider’s governing body. B. Appropriate mental health professionals who shall meet all professional requirements as

defined in the state licensing and certification laws relating to their respective professions. Mental health professionals include the following: 1. Psychiatrist, 2. Physician, 3. Psychologist, 4. Psychological Examiner, 5. Adult Psychiatric Mental Health Clinical Nurse Specialist, 6. Child Psychiatric Mental Health Clinical Nurse Specialist, 7. Adult Psychiatric Mental Health Advanced Nurse Practitioner, 8. Family Psychiatric Mental Health Advanced Nurse Practitioner, 9. Master of Social Work (Licensed in the State of Arkansas), 10. Registered nurse (RN; licensed in the State of Arkansas) who has one (1) year

supervised experience in a mental health setting (Services provided by the RN must be within the scope of practice specified by the RN’s licensure.),

11. Licensed professional counselor (Licensed in the State of Arkansas) and 12. Persons in a related profession who are licensed in the State of Arkansas and

practicing within the bounds of their licensing authority, with a master's degree and appropriate experience in a mental health setting, including documented, supervised training and experience in diagnosis and therapy of a broad range of mental disorders.

C. The services of a medical records librarian are required. The medical records librarian (or person performing the duties of the medical records librarian) shall be responsible for ongoing quality controls, for continuity of patient care and patient traffic flow. The librarian shall assure that records are maintained, completed and preserved; that required indexes and registries are maintained and that statistical reports are prepared. This staff member will be personally responsible for ensuring that information on enrolled patients is immediately retrievable, establishing a central records index, and maintaining service records in such a manner as to enable a constant monitoring of continuity of care.

D. A mental health paraprofessional is defined as a person with a Bachelor's Degree or a license from the Arkansas State Board of Nursing who does not meet the definition of mental health professional, but who is licensed and certified by the State of Arkansas in a related profession and is practicing within the bounds as permitted by his or her licensing authority, or a person employed by a certified RSPMI provider with a high school diploma or general equivalency diploma (GED) and documented training in the area of mental health. A mental health paraprofessional may provide certain Rehabilitative Services for Persons with Mental Illness under supervision of a mental health professional. The services paraprofessionals may provide are: crisis stabilization intervention, on-site intervention, off-site intervention, rehabilitative day service, therapeutic day/acute day treatment and collateral service. If the paraprofessional is a licensed nurse, the approved


services may also be provided: medication administration by a licensed nurse, routine venipuncture for collection of specimen and catheterization for collection of specimen.

213.100 Mental Health Paraprofessional Training 8-1-05

The RSPMI provider is responsible for ensuring all mental health paraprofessionals successfully complete training in mental health service provision from a licensed medical person experienced in the area of mental health, a certified RSPMI Medicaid provider, or a facility licensed by the State Board of Education before providing care to Medicaid recipients. A. The mental health paraprofessional must receive orientation to the RSPMI provider

agency. B. The mental health paraprofessional training course must total a minimum of forty (40)

classroom hours and must be successfully completed within a maximum time of the first two (2) months of employment by the RSPMI provider agency.

C. The training curriculum must contain information specific to the population being served, i.e. child and adolescent, adult, dually diagnosed, etc. The curriculum must include, but is not limited to: 1. Communication skills. 2. Knowledge of mental illnesses. 3. How to be an appropriate role model. 4. Behavior management. 5. Handling emergencies. 6. Record keeping: observing recipient, reporting or recording observations, time, or

employment records. 7. Knowledge of clinical limitations. 8. Knowledge of appropriate relationships with recipient. 9. Group interaction. 10. Identification of real issues. 11. Listening techniques. 12. Confidentiality. 13. Knowledge of medications and side effects. 14. Daily living skills. 15. Hospitalization procedures single-point-of-entry. 16. Knowledge of the Supplemental Security Income (SSI) application process. 17. Knowledge of day treatment models proper placement levels. 18. Awareness of options. 19. Cultural competency. 20. Ethical issues in practice. 21. Childhood development, if serving the child and adolescent population.

D. A written examination of the mental health paraprofessional’s knowledge of the 40-hour classroom training curriculum must be successfully completed.

E. Evaluation of the mental health paraprofessional’s ability to perform daily living skills (DLS) for mental health services must be successfully completed by means of a skills test.

F. The paraprofessional who successfully completes the training must be awarded a certificate. This certificate must state the person is qualified to work in an agency under professional supervision as a mental health paraprofessional.

G. In-service training sessions are required at a minimum of once per 12-month period after the successful completion of the initial 40-hour classroom training. The in-service training must total a minimum of eight (8) hours each 12-month period beginning with the date of


certification as a paraprofessional and each 12-month period thereafter. The in-service training may be conducted, in part, in the field. Documentation of in-service hours will be maintained in the employee’s personnel record and will be available for inspection by regulatory agencies.

A mental health paraprofessional who can provide documentation of training or experience in mental health service delivery may be exempt from the 40-hour classroom training. This does not exclude the paraprofessional from the requirement of successfully completing an examination and skills test.

All mental health paraprofessionals who provided mental health services for a Medicaid certified RSPMI provider on or before October 1, 1989, and since November 1, 1988, will be certified as mental health paraprofessionals. These mental health paraprofessionals may be exempt from the 40-hour classroom training. However, a written examination of the mental health paraprofessional’s knowledge of the 40-hour training course must be successfully completed and an evaluation of his or her ability to perform the daily living skills must be successfully completed by means of a skills test. A certificate must be awarded to the mental health paraprofessional and available for review by the Division of Medical Services staff upon request.


217.100 Primary Care Physician (PCP) Referral 8-1-05

A PCP referral is required for individuals under age 21 for RSPMI services except those listed in section 217.111. Verbal referrals from PCP's are acceptable to Medicaid as long as they are documented in the recipient's chart as described in section 182.100.

See Section I of this manual for an explanation of the process to obtain a PCP referral.

217.111 Procedure Codes Not Requiring PCP Referral for Recipients Under Age 21

8-1-05

Services designated by the following HCPCS procedure codes do not require PCP referral: A. 90801 – Diagnosis; B. 90885 – Treatment Plan; C. 90887 – Interpretation of Diagnosis; D. H2011 – Crisis Intervention and E. T1023 – Assessment/Reassessment and Plan of Care.

217.112 Medicaid Eligible at the Time the Service is Provided 8-1-05

A PCP referral is required. The referral is recommended prior to providing service to Medicaid-eligible children. However, a PCP is given the option of providing a referral after a service is provided. If a PCP chooses to make a referral after a service has been provided, the referral must be received by the RSPMI provider no later 45 calendar days after the date of service. The PCP has no obligation to give a retroactive referral.

The RSPMI provider may not file a claim and will not be reimbursed for any services provided that require a PCP referral unless the referral is received. If the PCP declines to provide the referral retroactive to the date of service, services may be billed beginning the date he/she completes the referral, or the date shown on the referral as the approved date. Medicaid will not cover the services provided prior to the date approved by the PCP. See section 182.000

217.113 Medicaid Ineligible at the Time the Service is Provided 8-1-05

A. When a child who is not eligible for Medicaid receives an outpatient mental health service, an application for Medicaid eligibility may be filed by the child or his or her representative.

B. If the application for Medicaid coverage is approved, a PCP referral is not required for the period prior to the Medicaid authorization date. This period is considered retroactive eligibility and does not require a referral.

C. A PCP referral is required no later than forty-five calendar days after the authorization date. If the PCP referral is not obtained within forty-five calendar days of the Medicaid authorization date, reimbursement will begin (if all other requirements are met) for services provided upon eligibility authorization and after, the date the PCP referral is received.

A PCP is given the option of providing a referral after a service is provided. However, the PCP has no obligation to give a retroactive referral. The RSPMI provider may not file a claim and will not be reimbursed for any services provided that require a PCP referral unless the referral has been received. See section 182.000.

To verify the authorization date, a provider may call EDS or the local DHS office. View or print EDS PAC contact information. View or print the DHS office contact information.


219.141 Services Available to Nursing Home Residents 8-1-05

The following RSPMI services may be provided to residents of nursing homes who are Medicaid eligible when the services are prescribed according to policy guidelines detailed in this manual: A. Diagnosis, B. Diagnosis – Psychological Test/Evaluation, C. Diagnosis – Psychological Testing Battery, D. Treatment Plan, E. Interpretation of Diagnosis, F. Individual Outpatient –Therapy Session, G. Crisis Intervention, H. Medication Maintenance by a Physician (limited to the administration of psychotropic

drugs) and I. Periodic Review of Treatment Plan/Plan of Care.

Services provided to nursing home residents may be provided on- or off-site from the RSPMI provider. The services may be provided in the long-term care (LTC) facility, if necessary.


224.000 Physician’s Role 8-1-05

RSPMI providers are required to have a board certified or board eligible psychiatrist who provides appropriate supervision and oversight for all medical and treatment services provided by the agency. A physician will supervise and coordinate all psychiatric and medical functions as indicated in treatment plans. Medical responsibility shall be vested in a physician, preferably one specializing in psychiatry, who is licensed to practice medicine in Arkansas. If medical responsibility is not vested in a psychiatrist, then psychiatric consultation must be available on a regular basis. For RSPMI enrolled recipients, medical supervision responsibility shall include, but is not limited to, the following: A. For any individuals certified as being Seriously Mentally Ill (SMI) or Seriously Emotionally

Disturbed (SED), the physician will see and evaluate the individual the earlier of 45 days of the individual’s entering care or 45 days from the effective date of certification of serious mental illness/serious emotional disturbance. This evaluation is not required if the recipient discontinues services prior to calendar day 45. The SMI/SED recipient must be seen again directly by a physician within one year after the date of the examination and at least every year thereafter.

B. For individuals not certified as having a Serious Mental Illness or Serious Emotional Disturbance, the psychiatrist or physician may determine through review of recipient records and consultation with the treatment staff that it is not medically necessary to directly see the enrolled recipient. By calendar day 45 after entering care, the physician must document in the recipient record that it is not medically necessary to see the recipient. If the recipient continues to be in care for more than six months after program entry, the psychiatrist or physician shall see and evaluate the individual directly by the end of six months, initially, then at least every year, thereafter.

C. The physician will review and approve the enrolled recipient’s RSPMI treatment plan/plan of care and document approval in the enrolled recipient’s record. If the treatment plan/plan of care is revised prior to each 90 day interval, the physician must approve the changes within 14 calendar days, as indicated by a dated signature on the revised plan.

D. Approval of all updated or revised treatment plans/plans of care must be documented by the physician’s dated signature on the revised document. The new 90-day period begins on the date the revised treatment plan is completed.


226.200 Documentation 8-1-05

The RSPMI provider must develop and maintain sufficient written documentation to support each medical or remedial therapy, service, activity or session for which Medicaid reimbursement is sought. This documentation, at a minimum, must consist of: A. The specific services provided, B. The date and actual time the services were provided (Time frames may not overlap

between services. All services must be outside the time frame of other services.), C. Name and title of the person who provided the services, D. The setting in which the services were provided, E. The relationship of the services to the treatment regimen described in the plan of care and F. Updates describing the patient’s progress.

Documentation must be legible and concise. The name and title of the person providing the service must reflect the appropriate professional level in accordance with the staffing requirements found in section 213.000.

For Therapeutic Day/Acute Day and Rehabilitative Day Services, progress notes must be entered daily. Daily notes may be brief; however, they must meet requirement of item F above. Providers may enter weekly progress notes that summarize the recipient’s progress in relationship to the plan of care.

All documentation must be available to representatives of the Division of Medical Services at the time of an audit by the Medicaid Field Audit Unit. All documentation must be available at the provider’s place of business. No more than thirty (30) days will be allowed after the date on the recoupment notice in which additional documentation will be accepted. Additional documentation will not be accepted after the 30-day period.


231.000 Introduction to Prior Authorization 8-1-05

The Division of Medical Services contracts with First Health Services and APS Healthcare to complete the prior authorization process.

When a provider requests PA for services to be provided via telemedicine, the procedure codes and modifiers (if any) listed below must be shown on the claim form, “telemedicine” must be specified on the request and “TOS V” (paper only) must be shown beside the procedure code.

A request for prior authorization for services to be provided to a foster child must specify that the request is for a foster child. A request for services to be provided to a child in the custody of the Division of Youth Services (DYS) must specify DYS custody.

231.100 PA for Under Age 21 8-1-05

Prior Authorization is required for certain services provided to Medicaid-eligible individuals under age 21. Prior authorization requests must be sent to APS Healthcare. View or print APS Healthcare contact information. Procedure codes requiring prior authorization:

National Codes Required Modifier

Type of Service Local Codes

H0004 HA 9 Z0568

90846 HA, U3 9 Z0571

90847 HA, U3 9 Z0571

90853 HA, U1 9 Z0574

H2012 HA 9 Z0577

H2011 HA, U6 9 Z1538

H2011 HA, U5 9 Z1539

H2015 HA, U5 9 Z1540

H2015 HA, U1 9 Z1541

H2015 HA, U8 9 Z1542

H2015 HA, U3 9 Z1543

90862 HA, UB 9 Z1545

H2017 HA, U1 9 Z1549

231.200 PA for Age 21 and Over 8-1-05

Certain RSPMI services must be prior authorized by First Health for individuals age 21 and over. The procedure codes listed below must be billed with type of service (TOS) R (paper only) when provided to Medicaid-eligible individuals age 21 or over. View or print First Health contact information. Procedure codes requiring prior authorization:

National Codes Required Modifier

Type of Service Local Codes

H0004 H0004

— —

R V

Z0568


90853 — R Z0574

H2012 UA R Z0577

H2011 U1 R Z1539

H2015 U6 R Z1540

H2015 U7 V Z1540

H2015 U2 R Z1541

H2015 U9 R Z1542

H2015 U4 R Z1543

90862 90862

— —

R V

Z1545

H2017 — R Z1549


252.100 Procedure Codes for Types of Covered Services 8-1-05

Covered RSPMI services are restricted services, non-restricted services, inpatient hospital services, services available through telemedicine, and services available to nursing home residents. RSPMI services are billed on a per unit basis. Unless otherwise specified in this manual or the appropriate CPT or HCPCS book, one unit equals 15 minutes.

NOTE: RSPMI providers will continue to use modifiers 22 and 52. Effective for claims with dates of service on or after November 1, 2005, modifier 22 will be replaced with UA and modifier 52 will be replaced by UB.

252.110 Non-Restricted Outpatient Procedure Codes 8-1-05

National Code

Required Modifier

Local Code

TOS Definition Max Units Per Day

for Services

Not Requiring

PA

92506 HA — 9 Diagnosis: Speech Evaluation 1 unit = 30 minutes Maximum units per state fiscal year (SFY) = 4 units

4

90801 HA, UI Z0560 9 Diagnosis The purpose of this service is to determine the existence, type, nature and most appropriate treatment of a mental illness or related disorder as prescribed in DSM-IV. This psychodiagnostic process must be provided by a Mental Health professional and must be supervised by a physician, as indicated by the physician’s dated, signed approval of the related treatment plan. It may include, but is not limited to, a psychosocial and medical history, a mental status examination, diagnostic findings and initial treatment plan/plan of care. This service may be billed for face-to-face contact as well as for time spent obtaining necessary information for diagnostic purposes and formulating the initial treatment plan/plan of care.

8

90801 — Z0560 V Diagnosis: Use the above description Additional requirement: 90801 with no modifier is for service provided via telemedicine only.

8


96100 HA, UA Z0561 9 Diagnosis - Psychological Test / Evaluation This service allows for the administration of a single diagnostic test to a client by a Psychologist or Psychological Examiner. This procedure should reflect the mental abilities, aptitudes, interests, attitudes, motivation, emotional and personality characteristics of the client as prescribed by the purpose of the evaluation.

8

96100 HA, UA, 52

Z0562 9 Diagnosis - Psychological Testing Battery This service allows for the administration of two (2) or more diagnostic tests to a client by a Psychologist or Psychological Examiner. This battery should assess the mental abilities, aptitudes, interests, attitudes, emotions, motivation and personality characteristics of the client.

8

90885 HA, U2 Z0563 9 Treatment Plan The plan of treatment for Medicaid recipients who are not SMI or SED is to be developed by a Mental Health Professional at the direction of the responsible physician in accordance with DBHS program standards and Section 224.000 of this manual. It must include short- and long-term goals for treatment of the client’s mental health needs and must be reviewed every ninety (90) days.

2 May be billed 1

time upon entering

care

90885 HA Z1578 9 Periodic Review of Treatment Plan/Plan of Care The periodic review and revision of the treatment plan/plan of care by a mental health professional to determine the recipient’s progress toward the treatment plan/plan of care objectives, appropriateness of the services provided and need for the enrolled recipient’s continued participation in the RSPMI program. This service must be completed every 90 days at a minimum. If performed more frequently, there must be documentation of significant acuity or change in clinical status (e.g., onset of psychotic symptoms or suicidal feelings) requiring an update in the recipient’s treatment plan/plan of care.

2


90885 HA, U1 Z1578 9 Periodic Review of Treatment Plan/Plan of Care Apply the above description. Additional information: 90885 plus modifier “U1” is for this service when provided by a non-physician.

2

90887 HA, U2 Z0564 9 Interpretation of Diagnosis This is a direct service provided by a Mental Health Professional for interpreting the results of diagnostic activities to the recipient and/or significant others. If significant others are involved, appropriate consent forms may need to be obtained

4

90887 U3 Z0564 V Interpretation of Diagnosis Use above description Additional information: 90887 plus modifier “U3” is for service provided via telemedicine only

4

H0004 HA Z0568 9 Individual Outpatient – Therapy Session Scheduled individual outpatient care provided by a Mental Health Professional to a recipient for the purposes of treatment and remediation of a condition described in DSM-IV and subsequent revisions.

4

H0004 — Z0568 R Individual Outpatient – Therapy Session Use above description. Additional information: H0004 with no modifier is for ages 21 and over.

4

H0004 — Z0568 V Individual Outpatient – Therapy Session Use above description. Additional information: H0004 with no modifier is for services provided via telemedicine only.

4


90846 HA, U3

Z0571 9 Marital/Family Therapy – Recipient is not present Marital/Family Therapy shall be treatment provided by a mental health professional to member(s) of a family in the same session. The purpose of this service is to treat the symptoms of the mental illness of the identified recipient by improving the functional capacity of the recipient within marital/family relationships. Documentation to support the appropriateness of excluding the identified recipient must be maintained in the recipient’s record.

6

90846

— Z0571 R Marital/Family Therapy – Recipient is not present Use the above description. Additional information: 90846 with no modifier is for ages 21 and over.

6

90846

U5 Z0571 V Marital/Family Therapy – Recipient is not present Use the above description. Additional information: 90846 with the modifier “U5” is for a service provided via telemedicine only.

6

90847

HA, U3 Z0571 9 Marital/Family Therapy – Recipient is present Marital/Family Therapy shall be treatment provided by a mental health professional to more than one member of a family in the same session. The purpose of this service is to treat the symptoms of the mental illness of the identified recipient by improving the functional capacity of the recipient within marital/family relationships. Additional information: 90847 plus modifiers “HA U3” is for under age 21.

6

90847

— Z0571 R Marital/Family Therapy – Recipient is present Use the above description. Additional information: 90847 with no modifier is for ages 21 and over.

6

90847

U5 Z0571 V Marital/Family Therapy – Recipient is present Use the above description. Additional information: 90847 with the modifier “U5” is for a service provided via telemedicine only.

6


92507 HA Z1926 9 Individual Outpatient – Speech Therapy, Speech Language Pathologist Scheduled individual outpatient care provided by a licensed speech pathologist supervised by a physician to a Medicaid-eligible recipient for the purpose of treatment and remediation of a communicative disorder deemed medically necessary. See the Occupational, Physical and Speech Therapy Program Provider Manual for specifics of the speech therapy services.

4

92507 HA, UB Z2265 9 Individual Outpatient – Speech Therapy, Speech Language Pathologist Assistant Scheduled individual outpatient care provided by a licensed speech pathologist assistant supervised by a qualified speech language pathologist to a Medicaid-eligible recipient for the purpose of treatment and remediation of a communicative disorder deemed medically necessary. See the Occupational, Physical and Speech Therapy Program Provider Manual for specifics of the speech therapy services.

4

92508 HA Z1927 9 Group Outpatient – Speech Therapy, Speech Language Pathologist Contact between a group of Medicaid-eligible recipients and a speech pathologist for the purpose of speech therapy and remediation. See the Occupational, Physical and Speech Therapy Provider Manual for specifics of the speech therapy services.

4

92508 HA, UB Z2266 9 Group Outpatient – Speech Therapy, Speech Language Pathologist Assistant Contact between a group of Medicaid-eligible recipients and a speech pathologist assistant for the purpose of speech therapy and remediation. See the Occupational, Physical and Speech Therapy Provider Manual for specifics of the speech therapy services.

4


90853 HA, U1 Z0574 9 Group Outpatient – Group Therapy A direct service contact between a group of recipients and one or more Mental Health Professionals for the purposes of treatment and remediation of a psychiatric condition. This procedure does not include psychosocial group activities.

6

90853 — Z0574 R Group Outpatient – Group Therapy Apply the above description. Additional information: 90853 with no modifier is for ages 21 and over.

6

H2012 HA Z0577 9 Therapeutic Day/Acute Day Treatment – 8 units minimum See Section 219.110 for service description.

32

H2012 UA Z0577 R Therapeutic Day/Acute Day Treatment – 8 units minimum H2012 with modifier “22” is for ages 21 and over. See Section 219.110 for service description.

32

H2011 HA, U7 Z1536 9 Crisis Intervention The purposes of this service are to prevent an inappropriate or premature more restrictive placement and/or to maintain the eligible recipient in an appropriate outpatient modality. This procedure is an unscheduled direct service contact occurring either on- or off-site between an eligible recipient with a diagnosable psychiatric disorder and a mental health professional.

8

H2011 U4 Z1536 V Crisis Intervention Apply the above description. Additional information: H2011 plus modifier “U4” is for service provided via telemedicine only.

8


99201 99202 99203 99204 99212 99213 99214 99215

HA, UB HA, UB HA, UB HA, UB HA, UB HA, UB HA, UB HA, UB

Z1544 9 Physical Examination – Psychiatrist or Physician A direct service contact provided to an enrolled RSPMI recipient by a psychiatrist or a physician to review a recipient’s medical history and to examine the recipient’s organ and body systems functioning for the purpose of determining the status of the recipient’s physical health. This procedure may occur either on- or off-site and may be billed only by the RSPMI provider. The physician may not bill for an office visit, nursing home visit or any other outpatient medical services procedure for the same date of service.

3

90862 HA Z1545 9 Medication Maintenance by a Physician Pharmacologic management, including prescription, use and review of medication with no more than minimal medical psychotherapy.

2

90862 HA, HQ Z0575 9 Group Outpatient - Medication Maintenance by a physician Group outpatient care by a licensed physician involving evaluation and maintenance of the Medicaid-eligible recipient on a medication regimen with simultaneous supportive psychotherapy in a group setting.

6

90862 — Z1545 R Medication Maintenance by a Physician Apply description above. Additional information: 90862 with no modifier is for ages 21 and over.

2

90862 — Z1545 V Medication Maintenance by a Physician Apply description above. Additional information: 90862 with no modifier is for services provided via telemedicine only.

2

90862 HA, UB — 9 Pharmacologic Management Psychiatric Mental Health Clinical Nurse Specialist or Psychiatric Mental Health Advanced Nurse Practitioner

2

36415 HA Z1913 9 Routine Venipuncture for Collection of Specimen Inserting a needle into a vein to draw the specimen with a syringe or vacutainer.

Per routine


90887 HA Z1547 9 Collateral Intervention, Mental Health Professional An on-site or off-site, face-to-face service contact by a mental health professional with caregivers, family members, gatekeepers, or other parties on behalf of an identified recipient to obtain or share relevant information necessary to the enrolled recipient’s assessment, treatment plan/plan of care and/or rehabilitation. Contact between individuals in the employ of RSPMI facilities is not a billable collateral intervention.

4

90887 U1 Z1547 V Collateral Intervention, Mental Health Professional Apply the above description. Additional information: 90887 plus modifier “U1” is for service provided via telemedicine only.

4

90887 HA, UB Z1548 9 Collateral Intervention, Mental Health Paraprofessional An on-site or off-site, face-to-face service contact by a mental health paraprofessional with caregivers, family members, gatekeepers, or other parties on behalf of an identified recipient to obtain or share relevant information necessary to the enrolled recipient’s assessment, treatment plan/plan of care and/or rehabilitation. Contact between individuals in the employ of RSPMI facilities is not a billable collateral intervention.

4

252.120 Restricted Outpatient Procedure Codes 8-1-05

The following restricted services may be provided only to Medicaid eligible recipients determined to be SMI or SED.


National Code

Required Modifier

Local Code

TOS Definition Max Units Per Day

T1023 HA, U1 Z1537 9 Assessment and Treatment Plan/Plan of Care The purpose of this service is to certify the enrolled recipient eligible for RSPMI restricted services based on diagnosis, past psychiatric history, level of functioning and present support needs, and to delineate the rehabilitative treatment and care to be provided during the certification period. This procedure must be completed by a Mental Health Professional and includes the initial assessment of rehabilitative care needs and the development of an individual treatment plan/plan of care for a recipient. Treatment plan is not complete until signed and dated by the physician.

Billed as 1 unit May be billed 1 time, upon admission to RSPMI services

T1023 — Z1537 V Assessment and Treatment Plan/Plan of Care Apply the above description. T1023 with no modifier is for services provided via telemedicine only.

Billed as 1 unit May be billed 1 time, upon admission to RSPMI services

H2011 HA, U6 Z1538 9 Crisis Stabilization Intervention, Mental Health Professional A scheduled direct service contact between an enrolled recipient and a mental health professional or paraprofessional for the purpose of ameliorating a situation which places the recipient at risk of 24-hour inpatient care or other more restrictive 24-hour placement. The service may be provided within the recipient’s permanent place of residence, temporary domicile or on-site.

12

H2011 U2 Z1538 R Crisis Stabilization Intervention, Mental Health Professional Apply the above description. Additional information: H2011 plus modifier “U2” is for ages 21 and over.

12


H2011 HA, U5 Z1539 9 Crisis Stabilization Intervention, Mental Health Paraprofessional A scheduled direct service contact between an enrolled recipient and a mental health professional or paraprofessional for the purpose of ameliorating a situation which places the recipient at risk of 24-hour inpatient care or other more restrictive 24-hour placement. The service may be provided within the recipient’s permanent place of residence, temporary domicile or on-site.

12

H2011 U1 Z1539 R Crisis Stabilization Intervention, Mental Health Paraprofessional Apply the description above. Additional information: H2011 plus modifier “U1” is for ages 21 and over

12

H2015 HA, U5 Z1540 9 On-Site Intervention, Mental Health Professional A direct service contact occurring on-site between a mental health professional or paraprofessional and an enrolled recipient. The purposes of this service are to obtain the full range of needed services, monitor and supervise the recipient’s functioning, establish support for the recipient and gather information relevant to the recipient’s treatment plan/plan of care.

6

H2015 U6 Z1540 R On-Site Intervention, Mental Health Professional Apply the above description. Additional information: H2015 plus modifier “U6” is for ages 21 and over.

6

H2015 U7 Z1540 V On-Site Intervention, Mental Health Professional Apply the above description. Additional information: H2015 plus modifier “U7” is for services provided via telemedicine only.

6


H2015 HA, U1 Z1541 9 On-Site Intervention, Mental Health Paraprofessional A direct service contact occurring on-site between a mental health professional or paraprofessional and an enrolled recipient. The purposes of this service are to obtain the full range of needed services, monitor and supervise the recipient’s functioning, establish support for the recipient and gather information relevant to the recipient’s treatment plan/plan of care.

6

H2015 U2 Z1541 R On-Site Intervention, Mental Health Paraprofessional Apply the above description. Additional information: H2015 plus modifier “U2” is for ages 21 and over

6

H2015 HA, U8 Z1542 9 Off-Site Intervention, Mental Health Professional A direct service contact occurring off-site between a mental health professional or paraprofessional and an enrolled recipient. The purposes of this service are the same as those for on-site intervention.

6

H2015 U9 Z1542 R Off-Site Intervention, Mental Health Professional Apply the above description. Additional information: H2015 plus modifier “U9” is for ages 21 and over.

6

H2015 HA, U3 Z1543 9 Off-Site Intervention, Mental Health Paraprofessional A direct service contact occurring off-site between a mental health professional or paraprofessional and an enrolled recipient. The purposes of this service are the same as those for on-site intervention.

6

H2015 U4 Z1543 R Off-Site Intervention, Mental Health Paraprofessional Apply the above description. Additional information: H2015 plus modifier “U4” is for ages 21 and over.

6


H2017 HA, U1 9 Rehabilitative Day Service, 192 units per week maximum A direct service rendered to enrolled recipients who have psychiatric symptoms that require medical rehabilitation in a more structured form of care than outpatient care for the purposes of maximum reduction of psychiatric symptoms, increased functioning and eventual assimilation into the community. This service is provided primarily in a day program setting by a mental health professional or a mental health paraprofessional. Services may be provided off-site when necessary as a part of the treatment program.

None

H2017 — Z1549 R Rehabilitative Day Service, 192 units per week maximum Apply the above description. Additional information: H2017 with no modifier is for ages 21 and over.

None


252.200 Place of Service and Type of Service Codes 8-1-05

Place of Service Paper Claims Electronic Claims

Outpatient Hospital 2 22

Doctor’s Office 3 11

Patient’s Home 4 12

Day Care Facility 5 52

Night Care Facility 6 52

Nursing Home 7 33

Skilled Nursing Facility 8 31

Ambulance 9 41

Other Locations 0 99

Comprehensive Outpatient Rehabilitative Facility

E 62

RSPMI Clinic (Telemedicine) H 99

Emergency Services in ER X 23 Type of Service

R - RSPMI - (age 21 and older for services requiring PA)

9 - RSPMI - (under age 21 and adults age 21 and older for services not requiring PA)

V – Telemedicine


252.420 Non-Covered Diagnosis Codes 8-1-05

RSPMI services are not covered by Arkansas Medicaid for an individual of any age whose primary diagnosis is substance abuse. A claim filed for any RSPMI service will be denied if the primary diagnosis code is listed below. 291.0 292.84 304.40 305.50

291.4 292.89 304.50 305.60

291.8 292.9 304.60 305.70

292.0 303.00 304.90 305.90

292.11 303.90 305.00 317

292.12 304.00 305.10 318.0

292.81 304.10 305.20 318.1

292.82 304.20 305.30 318.2

292.83 304.30 305.40 319

For an RSPMI provider delivering an RSPMI service, the primary diagnosis is the DSM-IV mental health disorder that is the primary focus of the mental health treatment service being delivered.

For persons being treated by an RSPMI provider for a mental health disorder who also have a co-occurring substance use disorder(s), this (these) substance use disorder(s) is (are) listed as a secondary diagnosis. Treatment plans should clearly reflect any services that may be needed to address the co-occurring substance use problems, whether offered by the RSPMI provider or via a referral to another provider. RSPMI providers that are also substance abuse treatment providers may also provide substance abuse treatment services to their mental health clients. These substance abuse treatment services are not billable as an RSPMI service. In the provision of RSPMI mental health services, the substance use disorder is appropriately focused on with the client in terms of its impact on and relationship to the primary mental health disorder. All RSPMI services must be focused toward and address the mental health needs of the client. Substance use issues should be addressed and documented within the context of the impact of the substance use disorder on the mental health disorder that is the focus of the RSPMI service being delivered.

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